Headache
Table 3: Recommended Drugs for Prophylactic Therapy of Tension-type Headache
Substance
Drug of First Choice Amitriptyline
Drugs of Second Choice Mirtazapine Venlafaxine
Drugs of Third Choice Clomipramine Maprotiline Mianserin
Daily Dose 30–75mg 30mg 150mg
75–150mg 75mg
30–60mg Level of Recommendation A
B B
B B B
The level of recommendation considers side effects and number and quality of the studies.
Table 4: Non-pharmacological Treatments for Tension-type Headache
Treatment
Psycho-behavioural Treatments Electromyograph biofeedback Cognitive-behavioural therapy Relaxation training
Physical Therapy Acupuncture
Level of Recommendation
A C C
C C
The level of recommendation considers side effects and number and quality of the studies. Comparison of Simple Analgesics
NSAIDs have been reported to be more effective than paracetamol in most,14,15,18–20
but not all,11,16,17 any particular NSAID is superior to any other.21,23,25,27,29
studies. It has not been demonstrated that NSAIDs have
more gastrointestinal side effects than paracetamol, but the use of large amounts of paracetamol may cause liver injury. Among NSAIDs, ibuprofen seems to have the most favourable side-effect profile.30
Combination Analgesics
The efficacy of simple analgesics and NSAIDs is increased by combination with caffeine 64–200mg.12,13,31–34
There are no comparative
studies examining the efficacy of combinations containing codeine. It is clinically well-known that caffeine withdrawal can cause headache, and chronic daily headache has been reported to be associated with use of over-the-counter caffeine combination products.35
It is
probable, therefore, that combinations of simple analgesics or NSAIDs with caffeine are more likely to induce MOH than simple analgesics or NSAIDs alone. Combinations of simple analgesics with codeine or barbiturates should not be used, because the latter increase the risk of developing MOH.35
Triptans, Muscle Relaxants and 0pioids Triptans most likely do not have a clinically relevant effect in patients with TTH,36,37
episodic TTH.38
neither have muscle relaxants demonstrated efficacy in Use of opioids increases the risk of developing MOH.35
Conclusions
Simple analgesics and NSAIDs are the mainstays of acute therapy of TTH (see Table 2). Paracetamol 1,000mg is probably less effective than the NSAIDs, but has a better gastric side-effect profile.39
400mg may be the drug of choice among the NSAIDs, because of its favourable gastrointestinal side-effect profile compared with other
66 Ibuprofen
Combination analgesics containing caffeine are more effective than simple analgesics or NSAIDs alone, but are regarded by some experts to be more likely to induce MOH.40
NSAIDs.39 Physicians should be
aware of the risk of patients developing MOH as a result of frequent and excessive use of all types of analgesics in acute therapy.9 Triptans, muscle relaxants and opioids are not recommended for the treatment of TTH.
Recommendations
Simple analgesics and non-steroidal anti-inflammatory drugs are recommended for treatment of episodic (acute) TTH. Combination analgesics containing caffeine are drugs of second choice. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache.
Prophylactic Drug Treatment of Tension-type Headache
Prophylactic pharmacotherapy should be considered in patients with chronic TTH, and it can be considered in patients with very frequent episodic TTH. Co-morbid disorders, e.g. overweight or depression, should be taken into account.
Amitriptyline
Lance and Curran have reported that amitriptyline 10–25mg three times daily is effective against TTH.41
10mg/day to be effective, but not 60mg/day,42
Diamond and Baltes found amitriptyline and amitriptyline
75mg/day reduced the duration of headache in the final week of a six-week study.43
Bendtsen et al.45
In another study, there was no difference in the size of the effect with amitriptyline 50–75mg/day, amitriptylinoxide 60–90mg/day and placebo.44
found that amitriptyline
75mg daily reduced the area under the headache curve (calculated as headache duration multiplied by headache intensity) by 30% compared with placebo, which was highly significant. Holroyd et al.46
treated
patients with antidepressants (83% took amitriptyline median dose 75mg/day and 17% took nortriptyline median dose 50mg/day) and compared the results with stress management therapy and with a combination of stress management and antidepressant treatment. After six months, all three treatments were approximately 30% more effective than placebo at reducing the headache index.
Amitriptyline should be started at low dosages (10–25mg/day) and titrated by 10–25mg weekly until the patient either achieves a good therapeutic effect or encounters side effects. It is important that patients are informed that this is an antidepressant agent which has an independent action on pain. The maintenance dose is usually 30–75mg daily administered one to two hours before bedtime to help to circumvent any sedative effects. The effect is not related to the presence of depression.45
be observed in the first week of treatment at the therapeutic dose.45
A significant effect with amitriptyline may If
the patient does not respond after four weeks on maintenance dose, it is therefore advisable to switch to other prophylactic therapy. The side effects of amitriptyline include dry mouth, drowsiness, dizziness, obstipation and weight gain.
Other Antidepressants
The tricyclic antidepressant clomipramine 75–150mg/day47 tetracyclic antidepressants maprotiline 75mg/day48 30–60mg/day47
and the and mianserin
have been reported to be more effective than placebo. Interestingly, some of the newer more selective antidepressants with action against serotonin and noradrenaline seem to be as effective as
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